Westmoreland Manor: Outdated Care Plans Risk Safety - PA
The discrepancy emerged during a state inspection in April that found the facility failed to keep care plans current for three residents, creating potential safety risks through outdated medical directions.
Resident 98's physician ordered blood glucose monitoring both morning and evening on January 15. But her care plan, dated January 27, still instructed staff to check her blood sugar only on Wednesday mornings. The Nursing Home Administrator confirmed during an April 9 interview that the care plan should have reflected the twice-daily monitoring requirement.
The 55-bed facility's own policy, updated February 1, requires care plans to be reviewed and revised at least quarterly or whenever changes occur. Yet inspectors found multiple instances where critical updates never happened.
Resident 135 faced a different problem. After requesting her shower time be moved from morning to evening, staff accommodated the change but never updated her care plan. Records from January through April showed she consistently received evening showers, but her care plan from June 2016 still indicated she preferred bathing on the day shift after breakfast.
The resident told inspectors on April 6 that she receives showers Tuesday evenings but would prefer to return to morning showers before breakfast. Nurse Aide 3 explained the next day that Resident 135 "frequently changes her mind related to shower times" and had requested the evening switch herself.
An interview between the Assistant Director of Nursing and Resident 135 on April 8 captured the confusion. The resident confirmed she was "an early shower" person but said "sometimes it was hard to get up in the morning, so she asked to be showered before bed."
The Director of Nursing acknowledged that Resident 135's care plan was never revised to reflect her actual shower schedule.
The most concerning case involved Resident 159, whose care plan contradicted strict physician orders designed to protect her safety. Doctor's orders from March 3 specified that the cognitively impaired resident should be non-weight bearing, could not use hoyer lifts, and was not to be out of bed due to medical and safety concerns.
But multiple care plans told a different story. One dated February 26 indicated she uses a wheelchair for locomotion. Another from February 2024 said she utilizes bilateral assist bars to transfer in and out of bed. A March 25 care plan directed staff to get her out of bed to an 18-inch specialty chair "as tolerated."
The annual assessment completed April 4 confirmed that Resident 159 was dependent on staff for all care needs and was not out of bed due to medical and safety concerns. Yet her contradictory care plans remained unchanged.
During an April 9 interview, the Director of Nursing confirmed that Resident 159's care plan had not been updated to reflect her current medical status and restrictions.
The inspection revealed that staff interviews and clinical records consistently showed the gap between what care plans directed and what residents actually needed or received. In each case, the facility had current information about residents' conditions and preferences but failed to incorporate those changes into the formal care planning process.
Facility policy required the interdisciplinary team to review and revise care plans after each Minimum Data Set assessment, a mandated evaluation of residents' abilities and care needs completed quarterly. The policy specifically stated that updates should occur "more often as changes occur."
For Resident 98, the quarterly MDS assessment completed March 12 documented that she was cognitively intact, dependent on staff for care needs, and had a diabetes diagnosis. The assessment should have triggered a care plan review that would have caught the discrepancy between her weekly blood sugar monitoring schedule and the physician's twice-daily orders.
Resident 135's significant change MDS from January 15 noted her diagnoses of anxiety and bipolar disorder along with her cognitive status and care needs. But the assessment process didn't capture or address her actual shower preferences and schedule.
The annual MDS for Resident 159 completed April 4 clearly documented her cognitive impairment, complete dependence on staff, and bed-only status for medical and safety reasons. The assessment provided all the information needed to update her care plans, but the revisions never occurred.
State inspectors classified the violations as causing minimal harm or potential for actual harm to the few residents affected. The findings represent a breakdown in the facility's quality assurance processes designed to ensure residents receive appropriate, individualized care based on their current conditions and needs.
The outdated care plans created situations where staff could potentially provide inappropriate care by following incorrect instructions, whether giving a diabetic resident inadequate blood sugar monitoring or attempting to mobilize a patient with strict bed rest orders.
Westmoreland Manor's failure to maintain current care plans violated Pennsylvania regulations requiring nursing services to reflect residents' actual care needs and medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westmoreland Manor from 2026-04-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on April 9, 2026.
Resident 98's physician ordered blood glucose monitoring both morning and evening on January 15.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Westmoreland Manor?
- Resident 98's physician ordered blood glucose monitoring both morning and evening on January 15.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GREENSBURG, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Westmoreland Manor or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395435.
- Has this facility had violations before?
- To check Westmoreland Manor's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.